The Mihalik Blog

Cultural Competency

Over the past month or so I’ve given three presentations on cultural competency.  Cross-cultural aspects of health care is a topic near and dear to my heart—one that I’ve been away from for way too long. 

 

While in medical school at the University of Pennsylvania, I was simultaneously enrolled in a graduate program in Anthropology.  I did my anthropological fieldwork in Guyana where I also practiced psychiatry in the Public Hospital in Georgetown.  The interesting part of the story is that I did my fieldwork between medical school and internship.  I was supposed to be a house officer at the Public Hospital but, on the day I arrived, the one-and-only psychiatrist working for the Ministry of Health decided to take an extended leave putting me, effectively, in charge of the 22 bed inpatient unit, the outpatient clinic, and all the psychiatric consultations in the hospital!!!  There was only one other psychiatrist in the entire country.  He had a private outpatient practice and would have nothing to do with the Ministry of Health. 

 

I have to admit it was a fascinating experience and when I returned to the United States

to start my internship, I didn’t have that sense of panic that interns so often do. 

I envisioned myself working at the crossroads of medicine and anthropology, which I dabbled in for a while before my career went in a different direction.  Now with the growing interest in cultural competency in health care, I see an opportunity to put my anthropological training to good use, once again.

 

The Office of Minority Healthof the US Department of Health and Human Services defines cultural and linguistic competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.  ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. ‘Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.”

 

I think one of the important concepts is that cultural competence is the ability to function in cross-cultural situations, not just knowledge of, and ability to function within, a specific culture.  Immersion in another culture is a classic method for training in cultural anthropology.  While immersion in a culture would be a wonderful component of training health care practitioners to improve cultural competency it is not very practical on a large scale. 

 

Another important aspect of the definition is that it refers to the “behaviors, attitudes, and policies” of a group, not an individual.  Cultural competence is an organizational achievement.

 

In future blogs I’ll discuss some methods to improve cultural competency. 

Free Online Courses

The Mihalik Group is launching free online courses through our website.  We plan to post approximately one course a month on topics of interest. 

 

The courses are all in PowerPoint format and are viewable directly from our website.

 

The first course, Changes to NCQA Health Plan Accreditation for 2009, launched today.  It is a relatively short presentation that highlights the major changes that go into effect July 1, 2009. 

Upcoming topics will include Complex Case Management, Disease Management, and Practitioner Office Site Visits. 

 

Check back frequently for new content. 

Member Redefined

When NCQA’s MBHO program was launched in the late 1990s, the term “enrollee” was used instead of the term “member,” which was used in the MCO program. 

 

Enrollees were just like members, but with a different name, mostly because NCQA viewed MBHOs as not having their own members the way health plans did.  Enrollees didn’t “belong” to the MBHO the way a member belongs to an HMO according to this logic. 

 

The distinction really had no practical significance from the standpoint of the NCQA standards but has created a duplicity of words that persists to the present day despite NCQA having retired the word enrollee a year or so ago. 

 

Not only did the word enrollee get retired but so did a longstanding concept that was a foundation of the MBHO standards.  From the inception of the MBHO accreditation program, NCQA limited the scope of standards that required member notification to members who had used the MBHO’s services.  This included a whole range of notification requirements, from the Member Rights and Responsibilities Statement, to the Affirmative Statement about Incentives for UM Decision-Makers, to information about the Accessibility of Health Care Services, among others. 

 

This limitation was explicitly written into the MBHO Standards and Guidelines.  The written explanation didn’t survive a revision of the manual somewhere in the last few years but the concept remained in place—certainly in the minds of surveyors who were familiar with the history of the program; in the way NCQA worded some of the explanations for various standards which implied, but did not explicitly state that the standard was required only for members who accessed services; and in written clarifications from NCQA’s Policy Clarification Support service. 

 

In a recent change that has not been communicated in any update or clarification, NCQA is now saying that member notification requirements apply to all of an MBHO’s membership—not just the ones who access services—unless there is a written prohibition, from a health plan for example, restricting contact with members who have not used services by the MBHO. 

 

Make no mistake, this is a significant change in compliance activities.  Coupled with the redefinition of the look back period that I discussed in a prior blog  MBHOs could be in the position of not having evidence of member notification for many standards stretching throughout the look back period. 

 

The Mihalik Group is here to helpwith all your accreditation needs.  We’ve got a great track record of helping organizations achieve NCQA accreditation with outstanding scores.  Examples include:  L.A. Care Health Plan. Community Care Behavioral Health, Memphis Managed Care, University of Miami Behavioral Health, and Cariten Healthcare, to name a few.

NCQA: Small Change, Major Implications

In late July NCQA issued a clarification regarding the meaning of the look back period for its accreditation and certification programs.  [To see the clarification, click here then click on the program of interest under the 7.28.08 date.]

 

Those of you who’ve been around NCQA accreditation for a while may remember when many standards required that the organization present evidence of compliance for a full year preceding the survey date.  Most of these requirements related to policies and procedures.  The expectation was that any and all versions of the P&P in place for the 12 months prior to the survey date needed to be fully compliant with the standards.  NCQA eliminated these requirements over a several year period. 

 

The look back period defines that period of time leading up to the survey date during which the organization must provide evidence of compliance with the standards.  For renewal surveys, the look back period is 24 months for most standards and for initial surveys, 12 months.  For standards with an annual requirement, such as evaluation of the QI Program, this means that for a renewal survey, the organization must present two evaluations—one dated sometime in the year preceding the survey and one approximately 12 months prior to that date.  For an initial survey, the organization would only need to present one, dated sometime in the 12 months before the survey. 

 

Evidence of compliance with standards that did not have such specific time frame requirements needed to be drawn from sometime in the look back period.  Policies and procedures needed to be approved and in place on the date of the survey but did not require an audit trail stretching back through the look back period, unless there was a specific requirement to the contrary.

 

That is all different now.

 

The new interpretation, effective July 28, 2008 , requires that organizations present evidence of compliance for the entire look back period.  For a renewal survey, that means all relevant versions of P&Ps stretching back for 24 months must be presented and must be fully compliant.  For other requirements, like notifying members affected by the termination of a practitioner, it means that examples should be drawn from the beginning, middle, and end of the look back period. 

 

The implications are significant.  For customized assistance on this or other accreditation related topics, contact The Mihalik Group.